Upstream: The Quest to Solve Problems Before They Happen

by Dan Heath

What Iton realized was that it wasn’t a particular thing that was causing the life expectancy gap. It was everything. “Fundamentally, what causes people to get sick and feel sick is a sense of a lack of control over what’s happening to them,” he said in a radio interview.

They’re struggling to find housing, they’re struggling to find good education, to avoid crime, to find jobs, to find healthy food, in some cases even potable drinking water. So low-income people in this country are ...

These communities were “incubators of ch...

The problem was not the lack of treatment. It was the lack of health.

How do you remake a system that’s hopelessly broken?

Now, imagine a black-mirror version of this story, outside the world of sports, where it’s the underdogs who lose, again and again, because the game has been rigged against them. Their bats are heavier, their gloves are smaller, the fences are pushed back, and in every direction, they must run through a bog. That’s in essence what Tony Iton had found

We’re celebrating this one kid—who deserves to be celebrated—but we’re not asking the real question: Why is this such a rare story?”

Systems are machines that determine probabilities.

what we don’t appreciate is that our celebration of her carries an implicit indictment of the environment we put her in. We forced you to climb Everest to get ahead in life—and you did it! Congratulations!

Upstream work is about reducing the probability that problems will happen, and for that reason, the work must culminate in systems change.

Because systems are the source of those probabilities. To change the system is to change the rules that govern us or the culture that influences us.

“There are these two young fish swimming along and they happen to meet an older fish swimming the other way, who nods at them and says ‘Morning, boys. How’s the water?’ And the two young fish swim on for a bit, and then eventually one of th...

A well-designed system is the best upstream intervention.

What’s the “water” you’re not seeing in your home life or at work? What’s interesting is that our kids can often see the water. They pick up on things we’re not even aware of.

For our children, we’re the system architects. We are the justice system, the housing department, social services, and (for a while at least) the education system.

What would the world look like if we extended half of the same concern to our neighbors’ kids and their futures?

No child should have to hit the green zeroes on a roulette wheel to succeed in life. A fair and just society is built on fair and just systems.

And as obvious as that may seem, even the people who strive for fairness and justice sometimes forget it. The tragedy of so much work in the social sector is that leaders tacitly...

They were the products of a system that offered inadequate opportunities. Had they been born inside a better system—say, a neighborhood six miles away—they likely would have earned income sufficient to survive subpar budgeting skills.

Think about this program through the lens of systems change. In some ways, the program actually entrenched the very inequalities that spawned it, by creating wonderful job opportunities for well-intentioned and well-educated leaders, but none for the people it was meant to serve.

How is it possible to escape the conclusion that this work would have excused school districts from funding the kinds of supplies that teachers desperately need; trained already overworked teachers to add fundraising to their job descriptions; and empowered private donors to be the gatekeepers who determine which resources can be used in the classroom, granting or withholding funding as they see fit.

DonorsChoose is a crutch for a broken and underfunded education system. And crutches are vital. They are also supposed to be temporary.

Part of every social-sector organization’s mission should be to push upstream. To prevent wounds as well as bandage them; to eliminate injustices as well as assisting those who suffered them.

efforts of many organizations to hire a more diverse workforce. The first thing to realize is that if you have a large organization filled with a relatively homogenous population

“Every system is perfectly designed to get the results it gets.”

But good intentions can’t overcome bad systems.

We’re casting our net for employees in a pond that’s shallower than we think. Or we’re valuing certain kinds of credentials that limit our pool of applicants while not contributing much to job performance. Or we’re filtering out candidates because of biases that we’re not even aware of.

(Small talk leads us to favor “likable” candidates—in other words, candidates who are just like us.)

Systems change starts with a spark of courage. A group of people unite around a common cause and they demand change. But a spark can’t last forever. The endgame is to eliminate the need for courage, to render it unnecessary, because it has forced change within the system. Success comes when the right things happen by default—not because of individual passion or heroism.

“The idea of this work is that you are part of something bigger than yourself,” said Iton. “You’re not helpless. You have an enormous amount of individual power and collective power.… Meaningful participation in democratic processes allows you to express agency, and agency is good for your health.”

“The law is just a set of rules based on inputs from power sources,” said Iton. “If you want to change the rules, you’ve got to change the power inputs so that the outcome will be different.”

It took many decades—centuries, really—to create these broken systems. It will require decades to fix them. Most institutions do not have patience denominated in decades. Foundations give grants for a few years; nonprofits see about a fifth of their employees turn over every year, on average.

Celedon, and hundreds of other leaders like her, are helping to uproot a system that tends to produce early death, and to plant in its place a new one that radically improves the probabilities for finding opportunity and health.

Because when it comes to preventing problems in complex systems, finding the right lever and fulcrum is precisely the hard part. In the last chapter, we saw that systems have great power and permanence; that’s why upstream efforts must culminate in systems change. At the same time, that power and permanence is exactly what makes systems change so difficult. So in the pursuit of systems change, where do you start?

You look for a point of leverage.

(Upstream leaders should be wary of common sense, which can be a poor substitute for evidence.)

These cases were not gang related. There was no strategy to this violence. The deaths were needless. And the circumstances were so ordinary. Anywhere there are teenage boys in the world, there will be fights over trivial stakes—bikes and basketball games. But in Chicago, those boys had access to guns, and they used them.

All of those are potential leverage points: moderating impulsivity or reducing alcohol consumption or restricting access to guns. The next question becomes: Can you identify an intervention that could plausibly accomplish one of those goals?

You can let your anger overwhelm you so that you act like a “savage,” Tony D taught them, or you can channel it to become a “warrior.” Anger could be a destructive force or a constructive one, he stressed, and we’re free to choose.

The Crime Lab researchers concluded that the BAM program had been successful in getting teenage males to slow down their thinking in fraught situations. A shouting match over a call in basketball could remain a shouting match, rather than escalating to a gunfight.

the strategy used by the Crime Lab’s

leaders to find those leverage points is closer to universal: Immerse yourself in the problem.

They weren’t satisfied with common-sense explanations for violence—they went back to the source.

The postmortem for a problem can be the preamble to a solution.

As an alternative to the focus on risk and protective factors, consider whether your leverage point might be a specific subpopulation of people.

When you can precisely target a group of people who are causing big problems on an ongoing basis, you can afford to spend a small fortune trying to help them.VI

A necessary part of finding a viable leverage point is to consider costs and benefits.

One of the most baffling and destructive ideas about preventive efforts is that they must save us money.

These aren’t irrelevant questions—but they aren’t necessary ones, either. Nothing else in health care, other than prevention, is viewed through this lens of saving money.

when he finally ends up needing heart bypass surgery, there’s literally no one who is going to ask whether he “deserves” the surgery or whether the surgery is going to save the system money in the long haul. When he needs the procedure, he’ll get it. But when we start talking about preventing children from going hungry, suddenly the work has to pay for itself. This is madness.